Provider Demographics
NPI:1376543173
Name:WATKINS, TOSHA E (MNT)
Entity Type:Individual
Prefix:
First Name:TOSHA
Middle Name:E
Last Name:WATKINS
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 RED COACH DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8323
Mailing Address - Country:US
Mailing Address - Phone:574-273-6787
Mailing Address - Fax:574-968-0882
Practice Address - Street 1:710 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3519
Practice Address - Country:US
Practice Address - Phone:574-273-6787
Practice Address - Fax:574-968-0882
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001429A133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN140630KMedicare ID - Type Unspecified